BCL-XL inhibitors enhance the apoptotic efficacy of BRAF inhibitors in BRAFV600E colorectal cancer

Metastatic BRAFV600E colorectal cancer (CRC) carries an extremely poor prognosis and is in urgent need of effective new treatments. While the BRAFV600E inhibitor encorafenib in combination with the EGFR inhibitor cetuximab (Enc+Cet) was recently approved for this indication, overall survival is only increased by 3.6 months and objective responses are observed in only 20% of patients. We have found that a limitation of Enc+Cet treatment is the failure to efficiently induce apoptosis in BRAFV600E CRCs, despite inducing expression of the pro-apoptotic protein BIM and repressing expression of the pro-survival protein MCL-1. Here, we show that BRAFV600E CRCs express high basal levels of the pro-survival proteins MCL-1 and BCL-XL, and that combining encorafenib with a BCL-XL inhibitor significantly enhances apoptosis in BRAFV600E CRC cell lines. This effect was partially dependent on the induction of BIM, as BIM deletion markedly attenuated BRAF plus BCL-XL inhibitor-induced apoptosis. As thrombocytopenia is an established on-target toxicity of BCL-XL inhibition, we also examined the effect of combining encorafenib with the BCL-XL -targeting PROTAC DT2216, and the novel BCL-2/BCL-XL inhibitor dendrimer conjugate AZD0466. Combining encorafenib with DT2216 significantly increased apoptosis induction in vitro, while combining encorafenib with AZD0466 was well tolerated in mice and further reduced growth of BRAFV600E CRC xenografts compared to either agent alone. Collectively, these findings demonstrate that combined BRAF and BCL-XL inhibition significantly enhances apoptosis in pre-clinical models of BRAFV600E CRC and is a combination regimen worthy of clinical investigation to improve outcomes for these patients.

Despite inducing objective responses in ~50% of melanoma patients [8], monotherapy using BRAF inhibitors such as vemurafenib, dabrafenib and encorafenib only induce objective responses in ~5% of BRAF V600E metastatic CRCs [9].This was attributed to relief of a negative feedback loop between ERK and the EGFR, leading to re-activation of MAPK/ERK signalling [10,11].Based on this observation, combination treatment with encorafenib (Enc) and the EGFR inhibitor cetuximab (Cet) were tested and found to significantly improve overall survival in BRAF V600E metastatic CRC patients [12,13], and is the current standard of care for these patients.While the Enc+Cet regimen represents a major advance in the treatment of BRAF V600E CRC, the improvement in overall survival (OS) is <4 months and objective response rates remain below 20% [13], warranting the need for further refinement of this treatment.
One limitation of BRAF and MAPK/ERK pathway inhibitors in general is their failure to induce substantial levels of apoptosis in CRC and other tumour cell types [11,14].Notably, this is despite these agents inducing the expression of the pro-apoptotic proteins BIM [15][16][17], BMF [17] and PUMA [15,17], and repressing expression of the pro-survival protein MCL-1 [16,18].
Notably, CRC cells have been reported to express high basal levels of pro-survival proteins, particularly BCL-X L [19].Herein, we considered the possibility that the high basal level of expression of pro-survival proteins may establish a high apoptotic threshold in CRC cells that cannot be overcome by BRAF inhibitors alone.To overcome this, we investigated the combinatorial use of BRAF inhibitors with BH3 mimetics, a class of anti-cancer compounds that mimic the function of BH3-only proteins to block the activity of pro-survival proteins [20].We found that both MCL-1 and BCL-X L are highly expressed in BRAF V600E CRC cell lines and that combining BRAF inhibitors with BCL-X L inhibitors significantly enhances apoptosis in these cell lines.We also demonstrate that this effect is at least partially dependent on the induction of BIM.Importantly, we further confirm this finding using two emerging strategies of BCL-X L inhibition, first using the BCL-X L targeting PROTAC DT2216 and second using the novel BCL-2/BCL-X L inhibitor dendrimer conjugate AZD0466 [21].Our pre-clinical findings demonstrate that the addition of BCL-X L inhibitors to BRAF inhibitor treatment is worthy of clinical investigation as a means of improving outcomes for BRAF V600E CRC patients.

Flow cytometry
Cells were seeded in 24 well plates and treated with drugs for 24 or 72 h.Both adherent and non-adherent cells were collected at completion of drug treatment and incubated overnight at 4 °C in 50 μg/mL propidium iodide diluted in sodium citrate buffer (0.1% sodium citrate (w/v) and 0.1% Triton X-100 (v/v)) (all from Sigma-Aldrich).Samples were then analysed on a BD FACSymphony A3 flow cytometer (BD Biosciences, Franklin Lakes, NJ, USA), by analysis of 10,000 events.Apoptotic cells were defined as having a sub-diploid DNA content and quantified using FlowJo V8.0 (FlowJo LLC, Ashland, OR, USA).Cell cycle analysis was performed using ModFit LT TM version 2.0 (Verity Software House, Topsham, ME, USA).

Clonogenic survival assays
Cells were seeded at 500 cells per well in 12-well plates and treated the following day with encorafenib (1 nM or 100 nM) alone and in combination with either A-1331852 (10 nM), S63845 (1 μM) or ABT-199 (1 μM).Colonies were then allowed to form over 10 days, at this point cells were fixed with 10% formalin for 5 min and stained with 0.1% crystal violet solution (Sigma-Aldrich) for 15 min at room temperature, washed with PBS and allowed to air dry.Analysis of clonogenic survival was performed using ImageJ (Java).

Generation of BIM knockout COLO 201 and LIM2551 cells
The COLO 201 and LIM2551 BIM knockout cell line was generated using the previously described doxycycline-inducible CRISPR-Cas9 lentiviral system [26].Briefly, cells were stably transduced with lentivirus expressing Cas9-mCherry and FACS sorted for mCherry positivity.Cells were subsequently transduced with lentivirus expressing GFP and the doxycycline-inducible sgRNA sequence targeting exon 3 of the human BIM gene (5′-GCCCAAGAGTTGCGGCGTAT-3′).Cells were double sorted for mCherry and GFP and subsequently maintained in vehicle or doxycycline (1 μg/ml).

Xenograft study
Six-week-old female NOD Scid gamma (NSG) mice were obtained from a colony maintained at the Austin Health BioResource Facility (Melbourne, Australia) and housed in specific pathogen free (SPF) microisolators.Mice were subcutaneously injected with 2 × 10 6 COLO 201 cells into the left and right flanks in a 1:1 mixture of matrigel matrix (75 μL)(Corning): DMEM/F12 (75 μL).Once tumours became palpable (~100 mm 3 ), mice were randomised to receive either vehicle control (n = 8 mice, 16 tumours), encorafenib (20 mg/kg, bi-daily, oral gavage) (n = 8 mice, 16 tumours), AZD0466 (103 mg/kg, once weekly, tail vein injection) (n = 8 mice, 16 tumours) or encorafenib plus AZD0466 (n = 8 mice, 14 tumours) for a total of 3 weeks.Tumours from one mouse were excluded from the combination arm due to an adverse event unrelated to treatment.Allocation of mice into groups was not blinded by the investigator.Sample sizes of the cohorts were based on previous experience, however no formal power analyses were performed prior to experimentation.Calliper measurements blinded to treatment group were performed a minimum of three times per week to measure tumour size.Investigators were not blinded at endpoint for tumour collection.Encorafenib was prepared in 50% PhosalPG (v/v), 27.5% PEG400 (v/v), 10% Ethanol (v/v) and 2.5% DMSO (v/v).AZD0466 was prepared in citrate/phosphate buffer.The study was approved by the Austin Health Animal Ethics Committee (A2018_05584).

Microarray analysis
Gene expression profiling was performed on 11 BRAF-mutant colorectal cancer cell lines treated with vemurafenib (5 μM) or DMSO control for 6 h, using the Affymetrix HG-U-133-Plus-2-Human Genome Array platform at the Peter MacCallum Cancer Centre genomics core facility (Melbourne, Australia).Affymetrix microarray.CEL files were imported into the Partek Genomics Suite version 6.6 (Partek, Chesterfield, MO, USA) and normalised using the Robust Multiarray Averaging (RMA) method.Normalised data was analysed using the Limma package.Affymetrix probes were determined to be differentially expressed between DMSO control and vemurafenib treatments if the adjusted p-value was <0.05.

Immunohistochemistry
Formalin-fixed paraffin-embedded sections (4 μm) were de-paraffinized and rehydrated through serial washes in xylene and ethanol.Sections were rinsed in H 2 O and quenched in 3% H 2 O 2 (Chemsupply) for 10 min.Antigen retrieval was performed by heating in Citrate buffer (pH 6.0) for 2 min at 1.0 power and 8 min at 0.2 power in the microwave.Slides were probed and incubated with anti-BIM (1:100, Cell Signalling Technology, 2933S) primary antibody at 4 °C overnight.Slides were then washed and incubated with Labeled polymer HRP-anti Rabbit (K4003, Dako) for 1-h at room temperature.Slides were washed and chromagen was developed using the DAB (3, 3-diaminobenzide) reagent (Dako).Sections were counter-stained using pre-filtered Mayer's hematoxylin (Amber Scientific, Australia) then dehydrated through serial ethanol and xylene washes prior to mounting using DPX mounting solution (Sigma-Aldrich).BIM expression was analysed using HALO software (Indica Labs, NM, USA).

BRAF inhibitors inhibit proliferation but have minimal effects on apoptosis in BRAF V600E
CRC cell lines BRAF inhibitor monotherapy induces objective responses in only ~5% of metastatic BRAF V600E CRC patients [9].While combination BRAF plus EGFR inhibitor treatment improves this to ~20%, overall survival is increased by only 4 months.One limitation of MAPK pathway inhibitors in general is that they predominantly induce cytostatic effects, and often fail to induce extensive levels of apoptosis [11,14].To investigate if similar effects occur upon BRAF inhibitor treatment of BRAF V600E CRC cells, we treated five BRAF V600E CRC cell lines with the BRAF inhibitors vemurafenib or encorafenib.Both inhibitors induced minimal to modest (<25%) apoptosis across all cell lines (Fig. 1A).Comparatively, both agents inhibited cell cycle progression in all five BRAF V600E CRC lines tested, illustrated by the significant reduction in the percentage of cells in S-phase and increase in the percentage of cells in the G0-G1 phase (Fig. 1B, Supplementary Fig. 1).
To determine if the limited effect of BRAF inhibitors on apoptosis extended to the clinically relevant encorafenib+cetuximab (Enc+Cet) combination, we treated the five BRAF V600E CRC cell lines with Enc+Cet.As observed for single agent BRAF inhibitor treatment, the combination regimen also induced minimal to modest (<25%) apoptosis across all cell lines (Fig. 1C), contrasting with the effect of the chemotherapeutic agent, irinotecan, which induced >50% apoptosis in two of five lines and >25% apoptosis in the remaining cell lines (Fig. 1C).

BRAF inhibitors prime BRAF V600E CRC cells for apoptosis
Inhibition of MAPK/ERK signalling has been shown to alter the apoptotic rheostat in tumour cells by inducing expression of several pro-apoptotic proteins and suppressing expression of several pro-survival proteins of the intrinsic apoptotic pathway [15,27].To determine if BRAF inhibitors induce similar effects in BRAF V600E CRC cells, we profiled gene expression changes in 12 BRAF V600E CRC cell lines treated with vemurafenib.As expected, vemurafenib treatment significantly reduced expression of the MAPK target genes FOSL1, FOS, SPRY2 and DUSP4 (Supplementary Fig. 2).Vemurafenib also significantly induced expression of the pro-apoptotic gene BCL2L11 (BIM) and repressed expression of the pro-survival gene MCL1, as well as a more modest suppression of BCL2L1 (BCL-X L ) (Supplementary Fig. 2).Expression of the proapoptotic gene BID and the apoptosis effector genes BAK1 and BOK were also downregulated by vemurafenib treatment, although the magnitude of repression was relatively modest.The induction of BIM and repression of MCL-1 were further confirmed at the protein level in the majority of the BRAF V600E CRC cell lines tested (Fig. 1D, Supplementary Fig. 2).The induction of BIM and suppression of MCL-1 protein was also observed following treatment with Enc+Cet (Fig. 1E).Collectively, these findings suggest that despite their relatively modest effects on apoptosis, BRAF inhibitors may prime BRAF V600E CRC cell lines to undergo apoptosis by altering the apoptotic rheostat.

BRAF V600E
CRCs express high levels of MCL-1 and BCL-X L As apoptosis is regulated by the balance of expression between pro-apoptotic and pro-survival proteins, we postulated that the magnitude of BIM induction and MCL-1 repression induced by BRAF inhibition may be insufficient to trigger apoptosis (BAX/BAK activation), if CRC cells express high levels of one or more prosurvival proteins.To investigate this, we interrogated the TCGA COAD RNA-seq dataset [28], as well as RNA-seq data from a large panel of CRC cell lines [29] to examine the basal expression levels of the major pro-survival proteins in CRCs.These analyses revealed higher expression of MCL1 and BCL2L1 compared to BCL2, BCL2L2 and BCL2A1 in both primary CRCs (Fig. 2A) and CRC cell lines (Fig. 2B).Analysis of the BRAF V600E subset of primary CRCs and CRC cell lines within these datasets also revealed the same overall trend of high basal mRNA expression of MCL1 and BCL2L1 compared to other pro-survival proteins (Fig. 2C, D, blue).Furthermore, comparison of BRAF V600E versus BRAF WT CRCs in these datasets revealed that MCL1 mRNA expression was also significantly higher in BRAF V600E tumours (Figs.2C and 2D, blue).This finding suggests that MCL-1 is further upregulated by mutant BRAF signalling, which is also consistent with the repression of MCL-1 following BRAF inhibitor treatment (Fig. 1D, S2).BCL2 and BCL2A1 levels were also higher in BRAF V600E compared to BRAF WT tumours (Fig. 2C, D, blue), although the overall level of expression was considerably lower than that of MCL1 and BCL2L1.Collectively these findings reveal that BCL-X L and MCL-1 are the most highly expressed pro-survival factors expressed in BRAF-mutant CRCs, and that MCL-1 is further upregulated in BRAF V600E tumours.

Combining BRAF inhibitors with a BCL-X L inhibitor induces extensive apoptosis in BRAF V600E CRC cell lines
To determine if the high basal levels of MCL-1 and BCL-X L in CRC cells may restrict their sensitivity to BRAF inhibitor (encorafenib) induced apoptosis, we tested the effect of combining encorafenib with BH3 mimetics targeting either MCL-1 (S63845), BCL-X L (A-1331852), or BCL-2 (ABT-199) on apoptosis in BRAF V600E CRC cell lines.Combining encorafenib with an MCL-1 inhibitor induced only a modest increase in apoptosis, surpassing 20% in only one (LIM2551) of the five cell lines tested (Fig. 3A).Comparatively, combination treatment of encorafenib with a BCL-X L inhibitor enhanced apoptosis to >50% in 3/5 BRAF V600E cell lines (Fig. 3B).Finally, consistent with the low levels of BCL-2 expression in BRAF V600E CRC cells and thus their likely independence on BCL-2 for survival, combination treatment with encorafenib and a BCL-2 inhibitor failed to enhance apoptosis to >25% in any of the cell lines (Fig. 3C).
Notably, HT29 and RKO cells were refractory to all BH3 mimetic + encorafenib combinations.While this may be due to the relatively Fig. 2 CRCs express high basal expression of BCL-X L and MCL-1.A Basal mRNA expression levels of pro-survival genes in human CRCs.Data obtained from the COAD cohort profiled by the cancer genome atlas (TCGA)(n = 266).B Basal mRNA expression of pro-survival genes in CRC cell lines.mRNA expression was extracted from n = 58 CRC cell lines profiled by RNA-seq analysis as previously reported [29].C Relative mRNA expression of pro-survival genes in primary BRAF WT versus BRAF V600E CRCs.Data obtained from the TCGA COAD cohort (WT, n = 236, BRAFmutant, n = 30).D Relative mRNA expression of pro-survival genes in BRAF WT versus BRAF V600E CRC cell lines.mRNA expression was extracted from n = 47 BRAF WT and n = 11 BRAF V600E CRC cell lines profiled by RNA-seq analysis by [29].low level of encorafenib-induced expression of pro-apoptotic (e.g BIM) in these lines (Fig. 1D), examination of basal mRNA expression of pro-survival factors revealed that RKO cells also expressed higher levels of BCL2 and BCL2A1 relative to the other cell lines, which may also contribute to its relative drug resistance (Supplementary Fig. 3).
Finally, to confirm these findings in longer term assays, we assessed the efficacy of these drug combinations in clonogenic survival assays in LIM2551 cells over 2 weeks.Consistent with the findings of the apoptosis assays, combining low-dose encorafenib with the BCL-X L inhibitor A-1331852 further reduced colon forming capacity in LIM2551 cells, whereas combining encorafenib with S63845 or ABT-199 had minimal additional effect (Supplementary Fig. S4A, B).
These findings reveal that combining a BRAF inhibitor with a BCL-X L inhibitor is a highly effective means of inducing apoptosis in BRAF V600E CRC cells.

BIM is required for BRAF + BCL-X L inhibitor-induced apoptosis
As BRAF inhibitor treatment also significantly enhanced BIM expression in BRAF V600E CRC cells (Fig. 1, Supplementary Fig. 2), we next assessed whether BIM was required for BRAF + BCL-X L inhibitor-induced apoptosis.To address this, we engineered a doxycycline-inducible CRISPR/Cas9 cell line to delete BIM in BRAF V600E COLO 201 and LIM2551 cells, and confirmed effective deletion of BIM following doxycycline treatment (Fig. 4A/ Supplementary Fig. 5A).Deletion of BIM significantly attenuated BRAF + BCL-X L inhibitor-induced apoptosis in COLO201 cells, as assessed by propidium iodide staining (Fig. 4B) and cleaved caspase 3 levels (Fig. 4C).A rescue of the apoptotic effect was also observed in LIM2551 cells albeit to a lesser extent (Supplementary Fig. 5B).While this finding demonstrates a direct role for BIM induction in BRAF + BCL-X L inhibitor-induced apoptosis, it also suggests that other factors are likely to be involved.

Combining encorafenib with next generation BCL-X L additively enhances apoptosis in BRAF V600E CRC cells in vitro and suppresses tumour growth in vivo
While our findings demonstrate that combining BCL-X L inhibitors with BRAF inhibitors robustly induces apoptosis in BRAF V600E CRC cells in vitro, the clinical use of BCX-X L inhibitors is currently limited by their induction of thrombocytopenia [30], an on-target toxicity driven by the high dependency of platelets on BCL-X L for their survival [31].Therefore, we sought to determine the efficacy of combining BRAF inhibitors with two recently emergent strategies for BCL-X L inhibition, designed to circumvent this limitation.First, we utilized DT2216, a proteolysis-targeting chimera (PROTAC) to target BCL-X L for degradation.DT2216 is a conjugate of the BH3 mimetic ABT263 and a ligand for the Von Hippel-Lindau (VHL) E3 ubiquitin ligase, which has minimal expression in platelets [32].The capacity of DT2216 to target BCL-X L for degradation in a dose-dependent manner was validated in the panel of five BRAF V600E cell lines (Fig. 5A).
Consistent with previous results, combinatorial treatment of DT2216 with encorafenib significantly enhanced apoptosis in a dose-dependent manner compared to either agent alone in COLO201, LIM2551 and LIM2405 cells whilst RKO and HT29 remained refractory to treatment (Fig. 5B).
Second, we determined the apoptotic effect of combining encorafenib with the recently developed BCL2/BCLXL inhibitor AZD4320 [33], and its drug dendrimer conjugate AZD0466, designed to minimise toxicity by gradually releasing AZD4320 by hydrolysis thus resulting in lower peak plasma levels, as well as through increased dendrimer retention within the tumour [21].Combination treatment of COLO 201 cells with encorafenib and AZD4320 in vitro, significantly enhanced apoptosis compared to either agent alone (Fig. 6A).To determine the efficacy of this combination in vivo, COLO 201 cells were grown as xenografts and mice treated with encorafenib (20 mg/kg, bid, oral gavage) and AZD0466 (103 mg/kg, once weekly, tail vein injection) alone or in combination for 22 days.The combination significantly  suppressed tumour growth compared to vehicle control either agent alone and also in tumour regression from treatment commencement (Fig. 6B-D).No significant change in body weight was observed with combination treatment over the duration of the experiment (Fig. 6E), collectively demonstrating that combining a BRAF inhibitor with the BCL-X L inhibitor AZD0466 may be an effective and tolerable treatment for BRAF V600E CRC.Consistent with our in vitro findings, immunohistochemical staining of resected tumours revealed an increase in BIM expression in mice treated with Encorafenib alone or in combination with AZD0466 (Fig. 6F, G).Somewhat surprisingly, analysis for apoptosis using TUNEL staining failed to reveal a significant difference between treatment groups, which may be due to tumour resection occurring 72-h post the final AZD0466 treatment, a period in which apoptotic cells may have been cleared from the tumour (data not shown).Collectively these findings demonstrate that combining a BRAF inhibitor with the BCL-X L inhibitor AZD0466 may be an effective and tolerable treatment for BRAF V600E CRC.

DISCUSSION
Metastatic BRAF V600E CRC carries an extremely poor prognosis and is in urgent need of better treatments.In this regard, a recent breakthrough was the approval of encorafenib plus cetuximab for treatment of chemorefractory BRAF V600E metastatic CRC patients [13].However, objective responses only occur in ~20% of patients and overall survival is only increased by ~4 months, warranting the search for strategies to enhance the efficacy of this treatment regime.Herein, we demonstrate that a limitation of BRAF inhibitors when used either alone or in EGFR inhibitors, is that they to effectively induce apoptosis in BRAF V600E CRC cell lines.Notably, despite their failure to induce apoptosis, we found that BRAF inhibitors induced expression of the pro-apoptotic protein BIM and repressed expression of the pro-survival protein MCL-1, suggesting these agents may prime BRAF V600E cells to undergo apoptosis.
An important element of this study was the investigation of the mechanism underpinning apoptotic resistance of BRAF V600E CRC cells to BRAF inhibitors, which was investigated by transcriptomic profiling of basal expression levels of pro-survival genes.This analysis revealed high basal expression of both MCL-1 and BCL-X L , and lower expression of BCL-2, BCL-w and BFL1 in all CRCs including the BRAF V600E subset.Notably, despite the high basal expression of both BCL-X L and MCL-1, a greater enhancement of apoptosis was observed when encorafenib was combined with a BCL-X L inhibitor compared to an MCL-1 inhibitor.While this finding may reflect differences in target inhibition between current BCL-X L and MCL-1 inhibitors, a further explanation may be the capacity of the encorafenib+BCL-X L combination to inhibit both BCL-X L as well as MCL-1, the latter through encorafenib-mediated transcriptional and/ or post-translational effects (Fig. 1).Comparatively, when encorafenib is combined with an MCL-1 inhibitor, the apoptotic threshold may remain elevated due to the sustained presence of high BCL-X L .In addition, we also demonstrate a key role for BIM induction in encorafenib+BCL-X L inhibitor-induced apoptosis.The encorafenibinduced transcriptional and/or post-translational stabilization of BIM [34][35][36][37], and suppression of MCL-1 expression, combined with a BCL-X L inhibitor, may result in sufficient levels of BAX and BAK being released from pro-survival proteins allowing BIM to activate BAX and BAK, and initiate apoptosis [38].
While these findings reveal that combining BRAF and BCL-X L inhibitors represents a promising therapeutic approach for BRAF V600E CRC, the clinical use of BCL-X L inhibitors is currently limited by their on-target toxicity of thrombocytopenia [30,31].We found that combining encorafenib with the BCL-X L degrading PROTAC DT2216 and AZD0466, a novel BCL-2/BCL-X L inhibitor-dendrimer conjugate [21,39], significantly enhanced apoptosis.Furthermore, combination of encorafenib with AZD0466 significantly reduced tumour growth in vivo and was generally well tolerated in mice.AZD0466 is currently being tested in phase I/II clinical trials for the treatment of haematological malignancies (ClinicalTrials.govidentifier: NCT05205161 and NCT04865419), and our findings suggest that combining encorafenib with AZD0466 may also be a promising approach for treating BRAF V600E tumours.
The concept of combining MAPK pathway inhibitors with BH3 mimetics has been explored in colorectal cancer and other tumour types.Specifically, a pre-clinical study in BRAF V600E melanoma demonstrated synergistic induction of apoptosis when BRAF or MEK inhibitors were combined with a MCL-1 inhibitor, which aligned with MCL-1 being the predominant pro-survival protein expressed in melanoma cells [17].A further study in KRAS-mutant NSCLC and other KRAS-mutant solid tumour cell lines also reported synergistic cell killing when MAPK pathway inhibitors were combined with BH3 mimetics [40].Excitingly, these studies have prompted the initiation of a clinical trial of the MEK inhibitor trametinib in combination with the BCL-2/BCL-XL inhibitor navitoclax in patients with advanced or metastatic solid tumours harbouring KRAS or NRAS mutations (Clinicaltrials.govidentifier: NCT02079740).
The high expression of multiple pro-survival proteins in CRC cells suggests alternative strategies for inducing apoptosis could be through the combined inhibition of BCL-X L and MCL-1.However, pre-clinical studies of these combinations have demonstrated acute liver toxicity, which is consistent with the cooperative role of BCL-X L with MCL-1 in hepatocyte survival [41,42].The current approach of using a targeted therapy (BRAF inhibitor) in combination with a BCL-X L inhibitor therefore has the potential to minimize these toxicities, while providing the added benefit of inducing pro-apoptotic proteins such as BIM.
In summary, our findings demonstrate that BRAF inhibitors alone and in combination with the EGFR inhibitor cetuximab fail to induce extensive levels of apoptosis in BRAF V600E CRC cells.Importantly, we reveal that this can be overcome by combining a BRAF inhibitor with a BCL-X L inhibitor, in both in vitro and in vivo models of BRAF V600E CRC, suggesting this combination regimen is worthy of clinical validation.

Fig. 4
Fig. 4 BRAF + BCL-X L inhibitor induced apoptosis requires BIM induction.A Validation of CRISPR-mediated deletion of BIM in COLO 201 cells.Cells were maintained in 1 μg/mL of doxycycline (+DOX) to induce BIM deletion and subsequently treated with encorafenib (100 nM) for 6 h to induce BIM expression.BIM expression [extra-long (BIM EL ), Long (BIM L ) and short (BIM S ) forms] was assessed by western blot with β-tubulin used as a loading control.B Control and BIM-deleted COLO 201 cells were treated with encorafenib (100 nM) and A-1331852 (10 nM) alone and in combination for 72 h and apoptosis determined by PI staining and FACS analysis.Values shown are mean ± SEM from a representative experiment performed in technical triplicate.Similar results were obtained in a second independent experiment.One-Way ANOVA, with Tukey's multiple comparison testing; ****(p≤0.0001).C Western blot analysis of cleaved caspase 3 (Cl.Caspase 3) induction following treatment of control and BIM-deleted COLO 201 cells with encorafenib (100 nM) plus A-1331852 (10 nM) for 12 h.β-tubulin was used as a loading control.

Fig. 6
Fig. 6 Anti-tumour effects of encorafenib plus AZD4320/AZD0466 on BRAF V600E CRC cells in vitro and in vivo.A COLO 201 cells were treated with encorafenib (100 nM) and AZD4320 (500 nM) alone and in combination for 72 h in vitro and apoptosis determined by PI staining and FACS analysis.Values shown are mean ± SEM from 3 independent experiments.Differences were compared using one-way ANOVA with Tukey's multiple comparison testing; ****(p ≤ 0.0001).B Effect of encorafenib and AZD0466 on the growth of COLO 201 xenografts.NOD scid gamma mice (n = 8 per group) were subcutaneously injected with 2 × 10 6 COLO 201 cells into the left and right flanks (n = 16 tumours per group except the combination treatment group where n = 14).Mice were then randomised to receive either vehicle control, encorafenib (20 mg/kg, b.i.d, og), AZD0466 (103 mg/kg, once weekly, I.V) or the combination, for 22 days.Tumour volume was determined by caliper measurements every second day and normalised to the volume at day 1 of treatment.Values shown are mean ± SEM. (C) Weight (g) and (D) representative images of excised tumours at experimental endpoint.Hash (#) depicts one less mouse (two less tumours) for the combination treatment group.E Relative change in mouse body weight from treatment commencement.Values shown are mean ± SEM.F Representative images of immunohistochemical staining of BIM in resected tumours and corresponding annotation performed using HALO software depicting areas of low (yellow), moderate (orange) and strong (red) BIM staining.G Quantification of BIM staining (percentage of positively stained tumour cells) in resected tumours.Values shown are mean ± SEM.Differences were compared using one-way ANOVA with Tukey's multiple comparison testing; *(p≤0.05),**(p≤0.01),***(p≤0.001) and ****(p≤0.0001).